Vehicular present from tpta it's not a good one but a great one

2. Why Early Mobility in the ICU?
Elena Murphy, PT
TPTA Fall Meeting
September 29, 2018

3. Learning Objectives
1. Describe current concepts and trends concerning the clinical problem of
delirium, including risk factors, etiologies, and adverse sequelae.
2. Apply specific assessment tools to evaluate altered mental function
and/or the presence and type of delirium.
3. Summarize clinical evidence and suggested inter-professional protocols
related to delirium, sedation/analgesia, ventilator management, and
early mobility.
4. Identify barriers to early mobility and harms of bedrest.
5. Recognize that early mobility is safe and feasible in the intensive are unit.
6. Discuss the benefits of early mobility with physicians and other
healthcare workers using evidenced based medicine
7. Be familiar with the available outcome measures available for the ICU
setting.

4. Wunsch JAMA 2010; 303: 849-856
Society of Critical Care Medicine, Critical Care Statistics in the United States, 2012
Annually
People Survive
a Critical Illness

5. Latronico Lancet Neurol 2011; 10: 931
60-80%
Physically
Impaired
Marcel
Oosterwijk
via
Flickr

6. ©
rustyrhodes
via
Flickr
50-70%
Cognitively
Impaired
Wolters Intensive Care Med 2013; 39: 376
Jackson AJRCCM 2010; 182: 183
Girard Crit Care Med 2010; 38: 1513

7. History
• As reviewed by Bergel, publications referencing the
benefits of early ambulation date back to the 1940s
• Burns stated: “It is our impression that by early
ambulation, weaning has been facilitated and hastened,
and the problems of prolonged bed and chair rest
minimized.”
Bergel, R. Rheum Dis Clin North Am 1990;16:791-801
Burns, J. Chest 1975;68:608

8. “Look at the patient lying long in bed.
What a pathetic picture he makes.
The blood clotting in his veins,
The lime draining from his bones,
The scybala stacking up in his colon,
The flesh rotting from his seat,
The urine leaking from his distended bladder,
And the spirit evaporating from his soul.”
Dr. Richard Asher, British Medical Journal, 1947

9. "Teach us to live that we may dread
Unnecessary time in bed.
Get people up and we may save
Our patients from an early grave”
Dr. Richard Asher, British Medical Journal, 1947

10. How do we get from this…..

11. ….to THIS?

12. BED REST versus IMMOBILITY
• Bed rest:
Medical treatment involving a
period of consistent day and
night recumbence in bed
• It is a procedure that can be
potentially harmful to patients
• It contributes to
deconditioning, NOT recovery
• Immobility:
“Immovable, fixed, not
moving, motionless ”
• In a young healthy adult,
45% of the body weight is
muscle
• Skeletal muscle strength
may decline 1% to 1.5 % per
day of strict bed rest
• When limbs are immobilized by
cast, the decline in strength
may be even more significant,
~ 5% to 6% per day
Crit Care Clin. 2007:23; 97‐110

13. • ICU acquired weakness
• Skeletal muscle atrophy
• Delirium
• Increased Anxiety
• Pressure sores
• Increased risk of secondary infections
Harms of Bed Rest

14. Does Weakness Really Matter?
ICU acquired weakness occurs in:
• 33% of all patients on ventilators
• 50% of patients with serious infection/sepsis
• 50% of patients who stay in the ICU at least one week
Society of Critical Care Medicine

15. ICUAW
• Predictor of:
- Prolonged weaning from ventilator (up to 20 days!)
- Mortality
• Effects are long lasting
- 60% with continued muscle dysfunction after 1 year
- Only 49% able to return to work
• Important contributor to post intensive care syndrome
(PICS)
Herridge et al NEJM 2011; 364:1293-1304
De Jonghe et al CCM 2007; 35:2007-2015
Leijten, F. JAMA 1995;274: 1221-1225
Bercker, S. Crit Car Med 2005;33: 711-715
Needham, D. Crit Care Med 2012
15

16. Independent predictors of ICU acquired
weakness:
Duration of mechanical ventilation
Days of multisystem organ failure
Corticosteroid administration
Female gender
ICU Delirium and ICU acquired weakness
are both predictors of poor outcomes;
synergistic relationship.
Kress, J. Crit Care Med 2009;37: S442-S447

17. ICUAW
• Generalized muscle weakness, which develops
during the course of an ICU admission and for
which no other cause can be identified
besides the acute illness or its treatment
• Influenced by illness, aggravated by treatment
Herridge, M. NEJM 2003;348: 683-693

18. • Multi-organ failure
• Sepsis/SIRS
• Prolonged immobilization
• Higher severity of illness on admit
• Hyperglycemia
• Age
• Vasopressors
• Aminoglycoside antibiotics
• Duration of MV
• ICU LOS
Risk Factors
Stevens Intensive Care Med 2007; 33: 1876-1891
Van den Berghe Neurology 2005; 64: 1348-1353
de Letter Crit Care Med 2001; 29: 2281-2286
Witt Chest 1991; 99: 176-184
De Jonghe JAMA 2002; 288: 2859-2867
Hermans Cochrane Database Syst Rev 1 2009

19. ICUAW
• Critical Illness Polyneuropathy (CIP)
• Critical illness Myopathy (CIM)
• Both

20. CIP
• Axonal degeneration
• microvascular changes in the endoneurium
evoked by sepsis

21. CIM
• Negatively affecting muscle structure and
function, all interacting in a complex manner
• Muscle atrophy

22. Clinical Signs
• Symmetrical and flaccid weakness of the
limbs, which is more pronounced in the
proximal muscles than in the distal muscles
• Facial and ocular muscles are often spared.
• CIP - reduced or absent sensitivity to pain,
temperature, and vibration.
• Respiratory muscles are often affected

23. • CIP is the main contributor to persistent disability,
whereas CIM can be associated with complete
recovery.
• Patients with CIM recovered within 6 months, whereas
those with CIP had a slower recovery or did not
recover.
• Mortality might be increased in patients with CIP.
• Specific diagnosis based on EP and muscle biopsy can
help to establish prognosis of chronic disability in
survivors of critical illness.
Prognosis
Lancet Neurology 2011; 10:931-941

24. • Medical Research Council (MRC) Sum Score
• Handgrip dynamometry
• Respiratory muscle strength
• Electrophysiological Testing
Diagnosis

25. MRC sum score
• Score ranges from 0 (total paralysis) to 60 (normal strength).
• The score is the sum of the MRC score of 6 muscles (3 at the
upper and 3 at the lower limbs) on both sides
• Each muscle graded from 0 to 5.
The following 6 muscles were examined:
Deltoid
Biceps
Wrist extensor
Ileopsoas
Quadriceps femoris
Tibialis anterior
Kleyweg R. Muscle Nerve 1991;14:1103-1109.

26. MRC-Muscle Grading Scale
Grade Degree of Strength
5 Normal Strength
4 Ability to resist against moderate pressure
throughout range of motion
3 Ability to move through full range of motion
against gravity. If a subject has a contracture that
limits joint movement, the mechanical range will
be to the point at which the contracture causes
joint restriction
2 Ability to move through full range of motion with
gravity eliminated
1 A flicker of motion is seen or felt in the muscle
0 No movement

27. • Aggressive treatment of sepsis
• Early mobility
• Preventing hyperglycemia
• Avoiding parenteral nutrition within the
first week of illness
Prevention

28. • Early mobility
• Neuromuscular electrical stimulation
• Bedside cycle ergometry
• Custom-designed technological aids to
assist with ambulation
PT Treatment

29. Is Early Mobility Safe In the ICUs?
 2007 the first report of early mobilization of mechanically ventilated patients was
published by Bailey et al.
» Adverse treatment events were EXTREMELY rare.
» NO unplanned extubations
 2008 Morris et all published the first prospective trial of mobilization vs usual care in
mechanically ventilated ICU patients.
» NO adverse events or unintentional removal of medial devices during
mobilization.
 2009, Burtin et al RCT that used bedside bicycle ergometer in med/surg ICUs.
» No serious adverse events occurred in the treatment group.

30. • PT/OT paired with sedative interruption and occurring
immediately from onset of MV is both feasible and safe
• Patients commonly required no sedation during therapy
sessions
• Awake, nondelirious state of mind occurred commonly
• Adverse events 16% of all therapy sessions (80 of 498): desat,
increased HR, ventilator asynchrony, agitation, device removal
(art line, NG tube, rectal tube, limb of vent disconnected)
Safety
Pohlman, M. Crit Care Med 2010;38: 2089-2094

32. Time to Rehab
Days after ICU Admission
0 5 8
2 3
1 4 6 7
Bailey (2007)
“Early Activity”
Bailey, Crit Care Med 2007; 35: 139-45
9
Schweickert
(2009)
“Early PT/OT”
Schweickert, Lancet 2009; 373: 1874-82
Morris, Crit Care Med 2008; 36: 2238- 2243
Morris (2008)
“Mobility Team”
Burtin (2009)
“Early Exercise”
ICU
Admission

33. Table 3. Outcomes (survivors)
Usual Care Protocol p
(n =135) (n= 45)
Days to first out of bed (adjusted*) 11.3 (9.6–13.4) 5.0 (4.3–5.9) <.001
Ventilator days (adjusted*) 10.2 (8.7–11.7) 8.8 (7.4–10.3) .163
ICU LOS days (adjusted*) 6.9 (5.9–8.0) 5.5 (4.7–6.3) .025
Hospital LOS days (adjusted*) 14.5 (12.7–16.7) 11.2 (9.7–12.8) .006
Data are presented as means (confidence intervals).
Adjusted*, adjusted for BMI, APACHE II, and vasopressors.
Early intensive care unit mobility therapy in the
treatment of acute respiratory failure.
Morris, P. Crit Care Med 2008;36: 2238-2242

34. • Two center randomized, controlled trial
• Study design: paired SAT/SBT protocol with PT/OT from earliest
days of mechanical ventilation
• N = 104
Wake Up, Breathe, and Move

35. Early
PT+OT
(n=49)
Usual
Care
(n=55)
P
ICU-acquired weakness 31% 49% 0.09
Ventilator-free days (out of 28) 23.5 21.1 0.05
ICU LOS 5.9 7.9 0.08
Hospital LOS 13.5 12.9 0.93
Hospital Mortality 18% 25% 0.53
Early PT/OT: Short-term outcomes
Schweickert, Lancet 2009; 373: 1874-82

36. Results of early exercise
• Return to independent functional status at d/c
• 59% in intervention group
• 35% in control group (p=.02)
Schweickert WD, et al. Lancet. 2009;373:1874-1882.

37. Early
PT+OT
(n=49)
Usual
Care
(n=55)
P
ICU Delirium (days) 2 (0-6) 4 (2-7) 0.03
Time in ICU with delirium 33% (0-58) 57% (33-69) 0.02
Hospital Delirium (days) 2 (0-6) 4 (2-8) 0.02
Hospital Days with Delirium 28% (26) 41% (27) 0.01
Early PT/OT and Delirium
Schweickert, Lancet 2009; 373: 1874-82

38. Variables that predicted readmission or death:
• Female gender
• Tracheostomy
• Charlson Comorbidity Index
• Early ICU mobility
Receiving Early Mobility During An ICU
Admission Is A Predictor Of Improved
Outcomes In Acute Respiratory Failure
Morris, P. Am J Med Sci 2011;341: 373-377

39. Legacies of severe lung injury:
• Exercise limitation
• Physical and psychological sequelae
• Decreased quality of life
• Increased costs
• Increased use of health care services
Functional disability 5 years after acute
respiratory distress syndrome
Herridge, MS. NEJM 2011;364: 1293-1304

40. Evidence-Based Mobility Benefits
• Greater functional independence at discharge
• ↓ duration of delirium
• ↓ time on ventilator
• ↓ length of hospital stay
• ↓ medical costs
• Improved neurocognitive outcomes Schweickert et al 2009; 373:1874-82
Chiang et al 2006; 86:1271-81
Needham et al 2010; 91:536-42
Morris et al CCM 2008; 36:2238-43

41. So… What Exactly Is Early Mobility?
Early Mobility Includes:
• Positioning
• Range of Motion
• Strengthening Exercises
• Chest Physical Therapy
• Breathing Exercises
• Education
• Mobilization
Team Members Include:
• RNs/PCTs
• Physical and Occupational
Therapists
• MDs
• Respiratory Therapists
• Pharmacists
• Family
Perme and Chandrashekar. Am J Crit Care 2009;

42. Know Your Role
Patient
PT/OT
RN
RT
Nurse
Aide
Family
MD

43. Perform safety screen first
Myocardial Ischemia
 No evidence of active myocardial ischemia (24 hrs)
 No arrhythmia require treatment in past (24 hrs)
Oxygenation inadequate (SaO2 <88%) on
 FIO2 ≤ 0.6
 PEEP≤ 10 cmH2O
Vasopressor(s)
 No  dose of any vasopressor infusion for at least 2 hours
Engagement to voice (lack of)
 Patient responds to verbal stimulation (ie, RASS -3)
Pass Fail
Exercise/Mobility
Therapy
Too Ill for
Exercise/Mobility
Schweickert WD, et al. Lancet. 2009;373:1874-1882.

44. Richmond Agitation-Sedation Scale
RASS
+4 COMBATIVE Combative, violent, immediate danger to staff
+3 VERY AGITATED Pulls to remove tubes or catheters; aggressive
+2 AGITATED Frequent non-purposeful movement, fights ventilator
+1 RESTLESS Anxious, apprehensive, movements not aggressive
0 ALERT & CALM Spontaneously pays attention to caregiver
-1 DROWSY Not fully alert, but has sustained awakening to voice
(eye opening & contact >10 sec)
-2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec)
-3 MODERATE SEDATION Movement or eye opening to voice (no eye contact)
-4 DEEP SEDATION No response to voice, but movement or eye opening
to physical stimulation
-5 UNAROUSEABLE No response to voice or physical stimulation

45. Hodgson C. Crit Care. 2014; 18(6): 658.
• Systematic literature review
• Meeting of 23 multidisciplinary ICU experts
• 94 international multidisciplinary ICU clinicians concurred
• Respiratory, Cardiovascular, Neurological and Other
Considerations

46. Patient 1
• Intubated
• RASS -1
• Femoral vas cath

47. Patient 2
• Intubated
• RASS +1
• Hemodynamicaly stable
• Hct 25

48. Patient 3
• Intubated
• RASS 0
• On levophed

49. Video
www.icudelirium.org

50. Physical Function ICU Test- scored

51. PFIT-s
• 4 Items
• < 5minutes to administer
• May use an assistive device to achieve
standing.
• Considers strength, endurance and level of
assistance in grading.

52. PFIT
1. Assistance required for sit to stand transfer.
Using an assistive device is not defined as assistance, only
physical assistance is recorded.
0=Unable 1=Assistx2persons 2=Assistx1 person
3 = No assistance
2. Cadence (steps/min) while marching in place.
Record the cadence (steps/min) and determine a score.
0=unable 1= > 0‐49 steps/min 2=50‐79 steps/min
3=80 or greater steps/min
3. Shoulder Flexion Strength
– Medical Research Council grading scale is used
4. Knee Extension Strength
– Medical Research Council grading scale is used

53. Advantages
• Developed specifically for use in the acute
care setting.
• In the ICU setting, this test has the most
established psychometric properties in terms
of reliability, validity and responsiveness.
(Parry, 2015)
• MCID 1.5 points on the 10 point interval scale
(Denehy, 2013)

54. Limitations
• Cannot be used with patients who are unable
to follow commands.
• Significant floor effect.
• No established cut off scores for D/C
destination or functional prognosis.

55. “If I must select an over all theme to our barriers with
sedation and mobility, it is the lack of empowerment we
give our patients.
“We look at our patients and interpret for them what
their needs are, we assume they will be harmed and
uncomfortable trying to mobilize without actually trying
it first.
“I always say my patients continue to surprise me by
doing better than I think they will.”
-Heidi Engel, PT, DPT, UCSF
27 years as a PT and 5 full-time in ICU

56. Delirium = Dangerous
Andros Island by N Rakov, NEJM 2011;365:457
Patient = Vulnerable

57. Delirium Key Features
(DSM-IV)
1. Disturbance of consciousness with reduced ability to focus,
sustain, or shift attention
2. A change in cognition or the development of a perceptual
disturbance that is not accounted for by pre-existing,
established, or evolving dementia
3. Develops over a short period of time and tends to fluctuate
over the course of the day
4. There is evidence from the H&P and/or labs that the
disturbance is caused by a medical condition, substance
intoxication, or medication side effect

58. Delirium: Key Features
1. Disturbance of consciousness with reduced ability to focus,
sustain or shift attention
2. A change in cognition or the development of a perceptual
disturbance that is not better accounted for by pre-existing,
established or evolving dementia
3. Develops over a short period of time and tends to fluctuate
over the course of the day
4. There is evidence from the H&P and/or labs that the
disturbance is caused by a medical condition, substance
intoxication or medication side effect

59. Cardinal symptoms of delirium & coma
Morandi A, et al. Intensive Care Med. 2008;34:1907-1915.

60. Delirium is a common clinical syndrome
characterized by:
Inattention
&
Acute cognitive
dysfunction
Delirium: Think rapid onset, inattention, clouding of
consciousness (bewildered), fluctuation
Fong et al. (2009) Nat Rev Neurology 5:210-220
Dementia: Think gradual onset, intellectual impairment,
memory disturbance, personality/mood change, no
conscious clouding

61. Delirium Subtypes
Alert & Calm
Combative
Agitated
Restless
Lethargic
Sedated
Stupor
Hyperactive Delirium
Hypoactive Delirium
Mixed
Delirium

62. “The time I spent [in the ICU] seems like it was in a huge, empty
gray space, sort of like a monstrous underground parking garage
with no cars, only me, floating or seeming to float, on something.
Every once in a while I would get to an edge of something horrible
and once I remember I thought, ‘if I just let go, then this horror
will be over’…
-SB
http://www.flickr.com/photos/travissmithphoto/490608085/

63. The patient experience

64. Is it really a big deal?
The Magnitude of the Problem

65. 2 4 4 5 6 7 9 11 12 13
21 25 26
34 38 40 42
65
92
101
119
178
0
20
40
60
80
100
120
140
160
180
200
Number
of
Articles
Year
Articles on delirium in the
ICU 1990-2011

66. Scope
• 30% of older adults experience delirium at some point
during hospitalization
• 10-50% of older surgical patients
• 10% Emergency Department patients
• 42% Hospice patients
• 16% patients in Post Acute Care settings
• Pre-existing dementia: delirium prevalence at least 50%

67. Scope
• Develops in ~2/3 of critically ill patients; 60-80% ICU
patients
• Vent: 50-80% occurrence
• Non-vent: 20-50% occurrence
• Hypoactive or mixed forms are the most common
• Undiagnosed in up to 72% of cases
Vasilevskis EE, et al. Chest. 2010;138(5):1224-1233.

68. 0 20 40 60 80 100
Bergeron, ‘01
Skrobik, ‘04
Ouimet, ‘07
Pandharipande, ‘07
Ely, ‘01
McNicoll, ‘03
Ely, ‘04
McNicoll, ‘05
Micek, ‘05
Thomason, ‘05
Prevalence of Delirium in the ICU
Medical
ICUs
(40%-80%)
Mixed
ICUs
(10%-40%)
Plaschke, ‘07
Pisani, ‘07
Lat, ‘09
Guenther, ‘09
Riker, ‘09
Girard, ‘08

69. Delirium in the ICU
MICU: 66 - 90%
Hyperactive 1%
Hypoactive 35%
Mixed 64%
CVICU: 26%
1 in 4 patients
Ely, et al., JAMA 2001; 286: 2703-2710 Ely, EW, et al. Crit Care Med 2001; 9:1370-1379
Peterson, et al., JAGS 2003; P394 Pandharipande, et al., J of Trauma 2008; 65:34-41
Trauma ICU: 67%
Hyperactive 2%
Hypoactive 60%
Mixed 6%
SICU: 73%
Hyperactive 1%
Hypoactive 64%
Mixed 9%

70. Delirium Pathophysiology
Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246

71. Patient Factors
Increased age
Alcoholism
Male gender
Living alone
Smoking
Renal disease
Environment
Admission via ED or
through transfer
Isolation
No clock
No daylight
No visitors
Noise
Use of physical restraints
Predisposing Disease
Cardiac disease (eg, HTN)
Cognitive impairment
(eg, dementia)
Pulmonary disease
Acute Illness
Length of stay
Fever
Medicine service
Lack of nutrition
Hypotension
Sepsis
Metabolic disorders
Tubes/catheters
Medications:
- Anticholinergics
- Corticosteroids
- Benzodiazepines
Less Modifiable
More Modifiable
DELIRIUM
Van Rompaey B, et al. Crit Care. 2009;13:R77.
Inouye SK, et al. JAMA.1996;275:852-857.
Skrobik Y. Crit Care Clin. 2009;25:585-591.

72. Risk Factors
• Baseline Vulnerability (predisposing)
• Risk factors related to person’s baseline
• Often we cannot modify these
• Precipitating
• These are things that happen to the patient
• Insults
• Often Iatrogenic
Baseline + Precipitating = Delirium

73. Framework for Risk
Baseline Vulnerability
Low
High
Mild/None
Noxious
Precipitating Stimulus

74. Framework for Risk
Baseline Vulnerability
Low
High
Mild/None
Noxious
Precipitating Stimulus

75. Framework for Risk
Baseline Vulnerability
Low
High
Mild/None
Noxious
Precipitating Stimulus

76. Nonpharmacologic Interventions
Pain:
• Monitor and manage pain using an objective scale
(e.g., FACES, BPS, VAS, CPOT, etc.)
Orientation:
• Convey the day, date, place, and reason for
hospitalization
• Update the whiteboards with caregiver names
• Request placement of a clock and calendar in room
• Discuss current events

77. Nonpharmacologic Interventions
Sensory:
• Determine need for hearing aids and/or eye glasses
• If needed, request surrogate provide these for patient when
appropriate
Sleep:
• Noise reduction strategies (e.g. minimize noise outside the room, offer
white noise or earplugs)
• Normal day-night variation in illumination
• Use “time out” strategy to minimize interruptions in sleep
• Maintain ventilator synchrony
• Promote comfort and relaxation (e.g., back care, oral care, washing
face/hands, and daytime bath, massage)

78. ICU Delirium: The Canary in the Coal Mine
3-fold increase in mortality
at 6 months
Each DAY a patients is
delirious = 10% INCREASE
in risk of death
Under recognized form of
organ dysfunction

79. Ely EW, JAMA 2004;291:1753-62

80. 0 1 2 3 4 5 6
Months
Survival
(%)
0
20
40
60
80
100
Persistently Comatose (n = 51)
Never Delirious (n = 41)
Ever Delirious (n = 183)
HR, 3.2; 95% CI, 1.4-7.7; P = 0.008
Ely EW, et al. JAMA. 2004;291:1753-1762.
3X death
Delirium and Mortality

81. Delirium Duration and Mortality
Pisani MA. Am J Respir Crit Care Med. 2009;180:1092-1097.
Kaplan-Meier Survival Curve
Each day of delirium in the ICU increases the hazard of
mortality by 10%
P < 0.001

83. Picture of Cognitive Impairment Following ICU Care

84. Delirium and Brain Atrophy
(A) 46 year old, no delirium (B) 42 year old, 12 days of delirium
Gunther M et al., CCM 2012;40:2022-32

85. Outcomes
• Delirium is an independent predictor of:
• Longer hospital stay
• Increased 6 month mortality
• 5x self extubation; >2x reintubation
• Higher ICU and hospital mortality
• Cumulative effect
Pun, B. T. & Ely, E. W. Chest 2007;132:624-636
Dubois MJ, et al. Intensive Care Med 2001;27:1297-1304
Miller RR, et al. Am J Respir Crit Care Med 2007;175:A791

86. Executive Functioning
• Executive functions are those involved in complex
cognitions such as:
• Planning
• Initiating
• Shifting/sequencing
• Monitoring and inhibiting
• This enables individuals to engage in purposeful, goal
directed behaviors.
Banich MT. Boston: Houghton Mifflin; 2004 1995
Lezak MD. 3rd ed. New York: Oxford University Press
Stuss DT, Levine B. Ann Rev Psychol 2007;53:401-33

87. Poor outcomes with Executive
Dysfunction
Independent Living/Functioning Deficits
 Decreased Independence
 Greater levels of care
 Financial Mismanagement
Poor healthcare management
 Poor medication adherence
 Resistance to care
 Inability to use medical devices
Employment Difficulties
 Unemployment
 Underemployment
 Poor work behavior
Impaired Social Functioning
 Interpersonal conflict
 Social maladjustment
Age Aging 2003 May;32(3):299-302.
Neurology 2002;59:1944-50.
J Int Neuropsychol Soc 2007;10:317-31.
Aging Ment Health 2004;8:374-80.
Am J Geriatr Psychiatry 2007;11:214-21.

88. Sedation Nightmares: Delirium-Induced
Flashbacks Plague Many Former ICU Patients
April 8, 2013
“drowning, poisoned by nursing, crawling on the floor of a walk-in
freezer full of amputated limbs” - Female Nurse Age 45
“Horror show of people trying to kill her, ants crawling on faces,
finding her self on a raft, in a space pod…in the Arctic, in the
desert….each with its own terrible narrative” – Maine filmmaker
and college professor
“You tend to believe you are the only one. You wonder what is wrong
with you? You made it out of the hospital, why can’t you get it
together?” – Filmmaker and college professor

89. Not only do survivors of the ICU suffer high rates of depression and
cognitive dysfunction, but also as many as one in three who are sick
enough to require a breathing tube also develop symptoms of PTSD.
“Too often we give people so much sedation that they can’t remember
anything and we are doing it in order to protect them. But now we
know that the total absence of memory is a driver of PTSD”
– Dr. Ely Vanderbilt University Medical Center
So, often, we’re lulled into thinking that we’ve done our job when these
people are wheeled out of the ICU. But we need to recognize that in
some cases, when people survive the ICU, their journey is only
beginning.” – Dr. Jackson Vanderbilt University Medical Center

90. Video
www.icudelirium.org

91. Post-Intensive Care Syndrome
SCCM Task Force on Long-Term Outcomes
New or worsening problems in physical, cognitive, or mental health
status arising after a critical illness and persisting beyond acute care
hospitalization.
ICU survivor or family member
Needham DM, et al. Crit Care Med. 2012;40(2):502-509.

92. Post Intensive
Care Syndrome
(PICS)
Family
(PICS-F)
Mental Health
Anxiety/ASD
PTSD
Depression
Complicated Grief
Survivor
(PICS)
Mental
Health
Anxiety/ASD
PTSD
Depression
Cognitive
Impairments
Executive
Function
Memory
Attention
Physical
Impairments
Pulmonary
Neuromuscular
Physical Function
Needham DM, et al. Crit Care Med. 2012;40(2):502-509.
Desai SV, et al. Crit Care Med. 2011;39(2):371-379.
Davidson JE, et al. Crit Care Med. 2012;40(2):618-624.

93. Employment Status
Of 12 month survivors, 47% employed at baseline:
• Of these previously employed survivors:
48% not working at 12 months
• 77% of these attribute unemployment due to
health-related reasons
Needham et al., BMJ, 2013; 346; f1532

94. Somatic Depression
• Depression is common in ICU survivors
• Prevalence rates approach 40%
• Symptoms are largely somatic
• Complaints largely pertain to loss of energy,
changes in appetite, and fatigue vs. sadness,
tearfulness and feelings of failure.
• Approaches led by physical therapy targeting physical
rather than cognitive causes could benefit ICU
survivors.
Jackson, JC. Lancet Resp 2014

95. Post-discharge Treatment Paradigms
• Employment of cognitive rehabilitation for survivors of acute/critical
illness.
• Used with patients with MS, HIV-AIDS, cancer (chemo-fog) and with
survivors of medical and surgical critical illness
• Goal Management Training (GMT) to target attention and
executive dysfunction.
• ICU Follow-Up Clinics: a potential model of post-discharge care
• Clinics widely used in Europe and increasingly in North America
• Typical focus on rapid identification of problems and on specialty
referrals
• Address combination of issues unique to ICU survivors
Engagement in physical therapy and exercise

96. Eligibility = RASS ≥ -3
Delirium Assessment
+4 COMBATIVE Combative, violent, immediate danger to staff
+3 VERY AGITATED Pulls to remove tubes or catheters; aggressive
+2 AGITATED Frequent non-purposeful movement, fights ventilator
+1 RESTLESS Anxious, apprehensive, movements not aggressive
0 ALERT & CALM Spontaneously pays attention to caregiver
-1 DROWSY Not fully alert, but has sustained awakening to voice
(eye opening & contact >10 sec)
-2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec)
-3 MODERATE SEDATION Movement or eye opening to voice (no eye contact)
-4 DEEP SEDATION No response to voice, but movement or eye opening
to physical stimulation
-5 UNAROUSEABLE No response to voice or physical stimulation

97. Confusion Assessment Method - ICU

98. CAM-ICU
• Assesses 4 aspects of a patient’s cognition and
arousal while in the intensive care unit.
– Acute change or fluctuating mental status
– Inattention
– Level of Arousal
– Disorganized Thinking

99. Advantages
• Developed specifically for use in the acute care
setting.
• Valid and Reliable (Gusmao-Flores, 2012)
• Prognostic indicators (Brummel, 2014; Balas,
2009; Abelha, 2013)
• CAM ICU positive is consistent with increased risk
for ADL dependency up to 1 year.
• CAM ICU positive is consistent with increased risk
for discharge to location other than home.

100. Limitations
• Provides measurement at the level of body
structure and function.
• Not as valid or reliable for use outside of the
ICU setting.

101. Confusion Assessment Method
for the ICU (CAM-ICU)
Feature 1: Acute change or
fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of
consciousness
Feature 4: Disorganized
thinking
Or
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5

103. Case #1: Mr. Icy
45 y/o man, lawyer with no previous memory or
attention problem
Dx: DKA, Intubated
In the past 24hrs the RASS scores have been -3 to
+1.
Step 1: Arousal Assessment
Currently: Awake and moving around restless in
bed, but not aggressive.
RASS = +1
What do we do next?

104. Step 2: CAM-ICU
- Feature 1:
Is he at his MS
baseline?
Fluctuation?
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1
- Feature 4
Pos Neg
Feature
1
Feature
2
Feature
3
Feature
4
Case #1: Mr. Icy

106. Step 2: CAM-ICU
- Feature 1:
Is he at his MS
baseline?
Fluctuation?
Other RASS Scores: -3
+1
- Feature 2:
Letters = 4 errors
- Feature 3:
RASS = +1
- Feature 4
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
Case #1: Mr. Icy

107. Case #2 Mrs. Dapple
75 y/o female
Dx: Severe pneumonia requiring prolonged
mechanical ventilation and difficulty weaning
In past 24 hours: RASS scores -3 to -1
Step 1: Arousal Assessment
Eyes closed, but awakens to voice; maintains eye
contact for >10 seconds
RASS = -1
What do we do next?

108. Step 2: CAM-ICU
- Feature 1:
Is she at her MS
baseline?
Fluctuation?
- Feature 2:
Letters = 1 error
- Feature 3
- Feature 4
Pos Neg
Feature
1
Feature
2
Feature
3
Feature
4
Case #2 Mrs. Dapple

110. Step 2: CAM-ICU
- Feature 1:
Is he at his MS
baseline?
Fluctuation?
RASS Variance: 2
- Feature 2:
Letters = 1 error
- Feature 3
- Feature 4
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
Feature
4
Case #2 Mrs. Dapple

111. Case # 3 Miss Universe
Miss Universe was successfully extubated
from the Vent at 0800. All sedation and
analgesia had been stopped earlier in the
AM. Yesterday evening and last night she
had periods of agitation with a documented
RASS range of -1 to +3.
Step 1: Arousal Assessment
Pt alert and calm.
RASS = 0
What do we do next?

112. Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you
aren’t sure
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4
Pos Neg
Feature
1
Feature
2
Feature
3
Feature
4
Case #3: Miss Universe

114. Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
RASS Variance = 4
- Feature 2:
Letters = 3 errors, but you
aren’t sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
Case #3: Miss Universe

115. Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you
aren’t sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered half the questions
wrong
Unable to perform 2-step
command
3 errors
Pos Neg
Feature
1
Feature
2
Feature
3
Feature
4
Case #3: Miss Universe

116. Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you
aren’t sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered half the questions
wrong
Unable to perform 2-step
command
3 errors
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
X
Case #3: Miss Universe

117. What if Miss Universe
had gotten all 4 of her
questions right?

118. Step 2: CAM-ICU
- Feature 1:
Is she at her MS baseline?
Fluctuation?
- Feature 2:
Letters = 3 errors, but you
aren’t sure.
Pictures = 4 errors
- Feature 3:
RASS = 0
- Feature 4:
Answered all 4 questions
correct
Unable to perform 2-step
command
1 error
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
X
Case #3: Miss Universe

119. Case # 4 Mr. Bubble
Mr. Bubble works as a traveling salesman, and has
been fully independent until admission. He is admitted
with acute pancreatitis. His sedatives were turned off
30 minutes ago for a Spontaneous Awakening Trial
(SAT).
Step 1: Arousal Assessment
Eyes closed, moves head to verbal stimulation, no eye
contact
RASS = -3
What do we do next?

120. Step 2: CAM-ICU
- Feature 1:
Is he at his MS
baseline?
Fluctuation?
- Feature 2:
Letters= no squeeze
for any letters
- Feature 3:
RASS = -3
- Feature 4:
Pos Neg
Feature
1
Feature
2
Feature
3
Feature
4
Case #4: Mr. Bubble

122. Step 2: CAM-ICU
- Feature 1:
Is he at his MS
baseline?
Fluctuation?
- Feature 2:
Letters= no squeeze
for any letters
- Feature 3:
RASS = -3
- Feature 4:
Pos Neg
Feature
1
X
Feature
2
X
Feature
3
X
Feature
4
Case #4: Mr. Bubble

123. The Back End of Critical Care
Must consider consequences of critical illness
Body: Disability, loss of functional
independence
Mind: Long-term cognitive impairment, PTSD
Pandharipande et al CC 2010; 14:157
Herridge et al NEJM 2011; 364:1293-1304
De Jonghe et al CCM 2007; 35:2007-2015
Girard et al CCM 2010; 38:1513-1520
123

124. BEGIN WITH THE END IN MIND…
Stephen Covey The 7 Habits of Highly Effective People

125. Mobility Protocol
Active ROM (in bed)
Sit/ Dangle
March/ Walk
Transfer
No Exercises,
but Passive
Range of Motion
allowed
Progress
as
tolerated
ICU
Discharge
Exercise
screen
RASS ≥ -3
RASS -5 / -4

126. RASS -5 / -4 RASS -3 / -2
Sitting Position
(Neuro chair or
chair position on
bed)
Minimum 20
minutes BID
Sitting on edge of bed (Dangle)
PT / RN / CP
RASS -1 / 0
Active ROM (Physical Therapy)
Q2 Hr turn assist
(Hill Rom bed)
Q2 Hr turning (patient assist)
Q2 Hr turning
Passive ROM
(RN / CP)
LEVEL I LEVEL II LEVEL III
DISCHARGE
TO
FLOOR
BED
LEGEND:
CLRT =
Continuous
Lateral
Rotational
Therapy
PT = Physical
Therapy
ADMIT
TO
ICU
CLRT based
on criteria Passive ROM
(RN / CP)
Exclusions:
Levophed ≥ 10mcg/min
or
MAP falls ≥ 10mmHg
when not supine
Sitting Position
(Neuro chair or chair position on bed)
Minimum 20 minutes BID
Exclusions:
Femoral art line or Femoral Vascath
Active Transfer to Chair (OOB)
PT / RN / CP Minimum 20 minutes / d
Ambulation:
(if appropriate by PT assessment)
•↑ FiO2 by 0.2 prior to activity
• Monitor O2 sats during / after
Exclusions:
≥ 60% FiO2 or PEEP ≥ 10 cm H2O
Progress
As
Tolerated